Chest Pain in an Urban Pediatric Cardiology Practice 133

Abstract

Evaluation of chest pain is the second most common reason for referral to our pediatric cardiology clinics. Chest pain generates anxiety for patient and parent, as well as frequent diagnostic testing. We sought to determine diagnostic testing patterns and their economic implications in the evaluation of chest pain in children and adolescents. We conducted a retrospective chart review of children and adolescents referred to our practice for initial evaluation of chest pain between 1992 and 1997, who had no pre-existing cardiac conditions. Of 347 children referred, 200 met these criteria. The mean age was 11.5 yrs. (3-19 yrs.), with 51% males. Pertinent past medical history included asthma (17%) and pectoral deformities (2%); pertinent family history included mitral valve prolapse (MVP) (5%), and early sudden death (3%). Chest pain was acute (<1 month) in 15%, chronic in 48%, and of unspecified length in 35%. Other chronic illnesses, primarily asthma, were present in 20%. Associated symptoms were present in 40%; most common were tachycardia (10.5%), dizziness (8%), and palpitations (7%). Chest pain occurred equally with activity and at rest. In only 7 cases (3.5%) was a cardiac abnormality identified: MVP (1%), benign arrhythmia (1.5%), hypertension (0.5%), and small secundum atrial septal defect (0.5%). In only 1 case was the chest pain thought to be related to a cardiac abnormality (mild MVP), and in no case was a serious or life-threatening condition identified. Other causes of chest pain identified included muscloskeletal pain (40.5%), asthma (5%), and obesity(2.5%). All but 1 patient had some diagnostic test: 69 (34.5%) had electrocardiogram (ECG) only; 66 (33%) had ECG and echocardiogram (ECHO),and the remainder had various combinations of ECG, ECHO and a variety of other tests, including Holter monitoring, stress testing, and event monitoring. Total charges were $210,300, or $1,051 per patient, including the outpatient visit, and technical and professional fees for tests performed (except charges for event monitoring, for which complete data were not available). Conclusions: Our data agree with previous studies that chest pain is not a harbinger of serious cardiovascular disease. In general, young patients who have life-threatening cardiac events do not have chest pain as a premonitory symptom. The cost of diagnostic testing in the evaluation of chest pain is high, and the yield is nearly zero. We believe no additional tests are required if the history and physical reveal a non-cardiac origin of chest pain, and that ECG alone should suffice if further testing is desired.